building permit €PTIC DISPOSAL PERMIT APPLICATI0N office use Only
742 Say Road,Queensbury,NY 12804
P:518-761-8256 Www,4ueensbury.net Permit#: 5afP
Tax Map ID X: 308.6-2-1 Permit Fee: ; Invoice #; I
Project Location: 516 Lucerne Road Septic Variance? Yes No
Pri ma ry own e r(s) HOLLY]RION -- --
Mailing Address 516 LUZERNE ROAD,QUEENBSURY NY
Phone & Email
installerf Builder SANrrARY SEWER SERVICES I
Mailing Address LUZERNE ROAD,QUEEN5BURYNY
Phone & Email 5187963760 -()WN O -
Engineer TOM CENTER BUILDING $ C)
Mailing Address 73 51iER]UAN STREET,GLENS PALLS,NY 12801 Des
Phone & Email TCENTER36L@YABOO.COM
Contact Person for Bu11ding& Code Corn ptiance: 6EORGF DRELLOS Phone; 5187963760
RESIDENCE INFORMATION;
Year Built It of bedrooms g gallons per bedroarn =total daily flow Garbage Grinder Yes 1'�-01
1980 or older I nstalled? {circle one)
1981-1991 Spa or Hot Tub Yes �v
installed? Pirtle one)
1992-Present 4 11.0 440
PARCEL INFORMATION:
Topography ,I Flat Polling Steep.Slope slope
Soil Nature Sand - Loam Clay Qtfrer
Groundwater At what depth? DEEPEWMAN 6' -
Bedrock/Impervious material At what depth? NONE -
Domestic Water supply _y/ Municipal Well (if well, water supply from any septic system absorption is_ft.�
Percolation Test Rate: V-S' per minute per inch crest to he completed by licensed engineer/ambitet:t)
PROPOSED SYSTEM rOR NEW CONSTRUCTION:
Tank size loon gallons{min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
SysteM Absorption field with 92 stone Total length ft.; Each Trench ft-
5eepage Pit with#3 stone How many- : Size-,
Atternative System Bed or other type: 20 X 30 FT BED
Holding Tank System I Total required capacity? ;tank size ;# of tanks
NOTES: 1, ACarm system& associated electrical work must be inspected by a Town approved electrical inspection
agency;2-We wilt no longer allow systems to be covered until suq:h tune as an as-built plan is received and approved-
The insta[led systern must match the septif layout on file—no exceptions.-
Declaration:Any permit or approval granted which is based upon or is granted in reIianre upon any material
representation or failure to rnake a material fact or rirrumStance known by or on behalf of an applicant, shall be void- I
have read the regulations tend agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage
DisposalOrdinance
PRINT NAME; DATE;
SIGNATURE:
i
Trmn of 0ows4ury 6ukslri}t$Lode Enforcement RpviSed FebrWry 7017